Provider Demographics
NPI:1508816786
Name:INTERNAL MEDICINE & PEDIATRICS OF TAMPA BAY PA
Entity Type:Organization
Organization Name:INTERNAL MEDICINE & PEDIATRICS OF TAMPA BAY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEMERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-961-2222
Mailing Address - Street 1:10111 WILSKY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625
Mailing Address - Country:US
Mailing Address - Phone:813-961-2222
Mailing Address - Fax:813-961-2220
Practice Address - Street 1:10111 WILSKY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625
Practice Address - Country:US
Practice Address - Phone:813-961-2222
Practice Address - Fax:813-961-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82542207R00000X, 208000000X
FLME87304207R00000X, 208000000X
207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267054200Medicaid
FL267056900Medicaid
FL267055100Medicaid
FL267056900Medicaid
FLK4651Medicare PIN
FLH92741Medicare UPIN
FL267054200Medicaid
FL267055100Medicaid